BCBSM Drug Claim Form

Shared by: wvd19904

Tags

blue cross blue shield of michigan, claim form, prescription drugs, prescription drug coverage, generic drugs, prescription drug, blue cross, health care, community blue, health insurance, blue care network of michigan, blue cross blue shield, employee benefits, prescription drug program, prescription drug benefit

Stats

views:: 7
posted:: 6/13/2010
language:: English
pages:: 3

Public Domain

Document Sample

INSTRUCTIONS FOR COMPLETING/SUBMITTING THE BLUE CROSS BLUE SHIELD OF MICHIGAN DRUG CLAIM FORM
(PLEASE TYPE OR PRINT ALL ENTRIES)
CLAIMS FROM PARTICIPATING PHARMACIES SHOULD BE SUBMITTED ELECTRONICALLY FROM THE PHARMACIST. Please
print the following information clearly in the appropriate areas on the claim form. If you are submitting more than one claim, each form
must be filled out completely. However, you may now submit up to six receipts per patient on one claim form.
The claim form must contain the following information in order to be processed:
1. CONTRACT NUMBER................................................Your nine-digit contract number on your Blue Cross and Blue Shield of
Michigan (BCBSM) I.D. card.
GROUP NUMBER.......................................................The group number or description found on your I.D. card.
COVERAGE/SERVICE CODE....................................The service code or description found on your I.D. card.
ENROLLEE/SUBSCRIBER LAST NAME, FIRST........Your complete last name followed by first name.
2. PROVIDER NAME, ADDRESS & NABP #.................. The name, address and NABP # of the pharmacy from which you purchased
the drug. The NABP # is required and the pharmacy can provide it.
3. PATIENT'S NAME, BIRTHDATE, SEX AND................Print patient's first name, birthdate, sex and mark the appropriate box to
RELATIONSHIP TO SUBSCRIBER. identify patient's relationship to the subscriber.
4. OTHER INSURANCE.................................................. If patient has other insurance besides BCBSM, mark YES and name the
the company. If not, check NO.
5. DATE OF SERVICE.....................................................Enter the date that the prescription was purchased.
PRESCRIPTION NUMBER..........................................The prescription number as it appears on the prescription order.
REFILL.........................................................................Enter "N" for original prescription or "Y" for refill.
QUANTITY...................................................................The quantity of the drug that you received from pharmacy (total number of pills).
DAYS SUPPLY............................................................The number of days supply for which the prescription is dispensed (taking
medicine for how many days).
DI DISPENSING INDICATOR......................................If doctor indicates on prescription dispense as written (DAW), mark "X"
in the box. If not, leave blank.
NATIONAL DRUG CODE............................................ Eleven-digit code which describes the drug dispensed. If you do not see this
on your receipt, you will be able to obtain this information from the pharmacy.
COMPOUND DRUG (CP)............................................Check here if compound drug.
MEMBER PAID............................................................The cost of the member paid for the prescription.
6. Line 1...........................................................................The complete name of the drug.
7. SUBSCRIBER ADDRESS............................................The complete address which is on file with Blue Cross and Blue Shield
of Michigan.
8. RECIPIENT SIGNATURE............................................Recipient of the prescription should sign in the space provided.
9. PHARMACIST'S SIGNATURE.....................................Sign in the space provided.

If you have another insurance plan which is primary, or are covered under Worker's compensation, please make sure to submit the claim
for reimbursement to the correct carrier.

PLEASE MAKE SURE TO ATTACH A COPY OF YOUR PAID PRESCRIPTION RECEIPT TO THIS FORM

PLEASE COMPLETE A NEW CLAIM FORM FOR EACH PATIENT FOR EVERY (6) DRUG RECEIPTS

Your claim can not be processed if any of the above information (with the exception of the Refill, DI and CP fields) is missing from the
claim form. Your claim will be returned for missing or incorrect information. If you are not sure what information to indicate on the claim
form (ie: NABP #, Quantity, Days Supply, etc) the pharmacy can provide you with the information.

BENEFITS
The Blue Cross and Blue Shield of Michigan Prescription Drug Program will pay for insulin and all drugs that bear the legend "Caution:
Federal Law prohibits dispensing drugs without a prescription," except those identified as exclusions. Disposable needles and syringes are
benefits under the Diabetic Supply Provision of the Prescription Drug Program.

EXCLUSIONS

.
Under most contracts, the following are NOT Prescription Drug Program benefits. Please consult your benefit booklet if you have a
question.

.
Drugs for which the pharmacy customarily charges less than your co-pay amount.

.
.
Contraceptives

Devices or appliances of any type and other non-medicinal substances.

.
.
Any experimental drug

All drugs purchased over the counter, except insulin.

WP 0420 AUG 05 Page 1 of 3
. Any covered drug which is entirely consumed at the time and place of service.

All drug claims with dates of purchase in excess of twelve months.
FIRST SUBMISSION PAYMENT SECOND SUBMISSION
CONTRACT NUMBER
TO PHARMACY NAME

SUBSCRIBER
GROUP NO. COVERAGE/ SERVICE CODE STREET ADDRESS

ENROLLEE/SUBSCRIBER LAST NAME FIRST CITY STATE ZIP CODE

PROVIDE NO. / NABP #

PLEASE COMPLETE ALL ITEMS ON FORM AND CONTACT PHARMACY FOR MORE INFORMATION IF NEEDED.
PATIENT'S FIRST NAME DATE OF BIRTH PATIENT'S SEX RELATIONSHIP TO SUBSCRIBER OTHER INSURANCE NAME
MO DAY YEAR M F SELF SPOUSE DEP YES NO

LINE DATE OF SERVICE PRESCRIPTION NUMBER REFILL QTY. DAYS DI NATIONAL DRUG CODE CP MEMBER PAID
NO. MO DAY YEAR SUPPLY

LINE 1 (NAME OF DRUG) LINE 2 (NAME OF DRUG) LINE 3 (NAME OF DRUG)

LINE 4 (NAME OF DRUG) LINE 5 (NAME OF DRUG) LINE 6 (NAME OF DRUG)

PAYMENT FOR THE ABOVE PRESCRIPTION SERVICE WILL BE PAID CERTIFICATION STATEMENT
TO THE SUBSCRIBER AND SENT TO THE ADDRESS ON FILE. "I certify that the patient for whom this claim is made is an eligible member in the Blue Cross and Blue
Shield of Michigan Drug Program, and that the prescription is for the sole use of that member. I
NAME OF SUBSCRIBER (PLEASE PRINT) hereby authorize the release of any information pertaining to claims under this contract from medical
or pharmaceutical records determined to be necessary by Blue Cross and Blue Shield.

STREET ADDRESS OF SUBSCRIBER
X
RECIPIENT SIGNATURE
CITY STATE ZIP CODE
PHARMACIST'S CERTIFICATION STATEMENT
I certify the amount noted above is my charge for the described service which was performed by me.

KEEP A COPY FOR ATTN: PHARMACY, MC B771
YOUR RECORDS. BLUE CROSS BLUE SHIELD OF MICHIGAN
MAIL ORIGINAL PO BOX 500
X
CLAIM FORM TO: PHARMACIST'S SIGNATURE
DETROIT, MICHIGAN 48231-0500

AFTER YOU HAVE COMPLETED THE CLAIM FORM

.
Please review your claim form to be sure it is filled out correctly. This will enable us to process your purchases promptly.

Make sure to tape a copy of your paid receipts from the pharmacy indicating the
detailed information for the prescription dispensed to this form. Do not overlap
receipts, or cover necessary information. If additional space is needed, please

. use a separate sheet of 8 1/2" x 11" paper - do not use the back of the sheet provided.

Please contact the BCBSM Service Center telephone number noted on your BCBSM

. Identification card with questions.

Mail to: Attn: Pharmacy, MC B771
Blue Cross Blue Shield of Michigan
P.O. Box 500

. Detroit, Michigan 48231-0500

. Keep a copy for your records.

Our response will be sent to you as soon as possible.

PLEASE MAKE SURE TO ATTACH A COPY OF ALL YOUR RECEIPTS TO THE PAPER PROVIDED. IF ADDITIONAL SPACE IS
NEEDED, PLEASE USE A SEPARATE SHEET OF 8 1/2" X 11" PAPER - DO NOT USE THE BACK.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
WP 0420 AUG 05 Page 2 of 3
TAPE (DO NOT STAPLE) COMPUTERIZED RECEIPTS OR ITEMIZED BILLS TO THE FRONT OF THIS PAGE ONLY

overlap receipts. If additional space
* Do not use a separate sheet of 8 1/2" x 11" is needed,
please paper. Do
not use the back of this sheet

Rx 1 Rx 2 Rx 3
Tape Receipt Here Tape Receipt Here Tape Receipt Here

Rx 4 Rx 5 Rx 6
Tape Receipt Here Tape Receipt Here Tape Receipt Here

CLAIMS PAYMENT INQUIRY
Allow a minimum of 45 days from submission of original Claim for Payment before sending a follow-up, unless a payment or rejection
notice was received. If you are questioning a partial payment or rejection, please contact your local BCBSM Customer Service Office for
further information and inquiries. You will find the customer service number on the back of your card. Request for additional claim forms
should be sent to:
Attn: L800
Blue Cross Blue Shield of Michigan
53200 Grand River
New Hudson, MI 48165-9801
WP 0420 AUG 05 Page 3 of 3

Related docs